Licensed Clinical Psychologist

Chapter I

Just as the baby was coming out, it wrapped the cord around its neck and strangled itself. Himself. A boy —Anthony Jr. As my father talked, tears dripped down the side of his face like candle wax. The sight shocked me; until that moment, I had assumed that men were as incapable of crying as they were of having babies (Lamb,1992, p. 12 ).

Introduction

The above quote is a strong illustration of the emotional vicissitudes that fathers experience in response to perinatal loss. More specifically, this quote depicts the unexpected and traumatic nature of this type of loss, as well as the significant impact it can have on fathers. Although thousands of fathers undergo perinatal losses each year, there are relatively few studies that examine how these men respond to and cope with such an event. Furthermore, there are no studies that examine how perinatal loss impacts the conscious and unconscious experiences of such men. Without this research, the understanding of how fathers grieve after these losses is limited. Therefore, this dissertation will seek to explore fathers' conscious experiences and the underlying unconscious processes following perinatal loss.

Although the term “perinatal loss” originally referred to all reproductive losses happening between the twentieth week of pregnancy and the first month of life (Leon, 1992), more recent trends have been more inclusive and tended to include a wider range of losses. Hence, this dissertation has used the broader definition of perinatal loss and includes losses that occur before the twentieth week of pregnancy, as well as ones that occur up to six months after birth. Therefore, in addition to stillbirth, ectopic pregnancy,and miscarriage, neonatal death and Sudden Infant Death Syndrome will also be included in the definition.

Unfortunately, perinatal losses occur frequently. Recent statistics document that 20% of pregnancies end in miscarriage and ectopic pregnancy, 1.5% of pregnancies end in stillbirth (Mikel and Stohner, 1995), and .04% of live births end in SIDS (National Center for Health Statistics [NCHS], 1996).

There are several variables that complicate the process of grieving perinatal losses. For instance, parents have few memories of the lost child. Without many memories of the baby, parents may be unclear for whom they are grieving, and feel confused about what they are experiencing. In addition, mourning a perinatal loss primarily involves prospective mourning, which is “the relinquishing of wishes, hopes, and fantasies of what could have been but never was” (Leon, 1990 p. 35). This type of mourning differs from the mourning required in later losses (i.e., the lost of a friend or spouse), in that later losses primarily require the mourner to focus on past experiences with the lost individual.

There are also various psychodynamic issues associated with perinatal loss that complicate the mourning process. For instance, there is some evidence that parents regress during pregnancy; therefore, they lose a baby when they are already in a vulnerable state (Leon, 1990). Furthermore, parents often feel ambivalent about the pregnancy, having a baby, and about becoming a parent. Hence, they may think the loss is a result of their own forbidden wish not to have a child (Condon, 1986). In addition, because parents commonly see their child as narcissistic extensions of themselves, losing their baby or fetus can feel like losing a part of themselves.

Perinatal loss may also interfere with some adult developmental tasks. During each “critical period” of a child’s development, parents re-experience their own childhood phases and have the opportunity to rework them and achieve a new level of organization (Parens, 1975). Because with a perinatal loss adults are losing the chance of having a child, it can delay or interfere with further adult development.

Statement of the Problem

While it takes both a mother and a father to create a baby, the mother is the one who primarily receives support and empathy when a perinatal loss occurs. Yet these losses can be significant for fathers, too. An expectant father, like his wife, has often had fantasies of his baby, imagined what he, himself, would be like as a father, and thought about what his relationship might be like with his child (Zayas, 1987). Therefore, when he loses the baby, he is not only mourning the loss of his child, but also grieving the loss of the opportunity to be a father. These issues bring up a salient question: Why is it that when a perinatal loss occurs, fathers are put on the “back burner,” or given the job of arranging the funeral instead of being viewed as a griever? This phenomenon probably stems from several sources, including the difficulty that men have in expressing emotions (Puddifoot & Johnson, 1997), the fact that men do not have a biological connection to the pregnancy, and society’s expectation that this loss is not theirs to grieve.

Although the psychological impact of perinatal loss has become more widely recognized and examined in the past twenty years, the existing literature primarily focuses on the mothers’ reactions to the loss. Historically, few studies have examined the fathers’ responses to perinatal loss. Furthermore, most of the existing perinatal loss research on fathers has compared the degree and duration of fathers’ and mothers’ grief to each other, concluding that fathers grieve less than mothers (Beutal et al., 1996; Theut et al., 1990; Vance et al., 1991). The bulk of those studies, however, measure variables that are more suited to assess mothers’ distress, such as conscious manifestations of anxiety, depression, sadness, guilt, thoughts about the loss, and feelings about the loss. Because fathers may not directly express their feelings about or consciously grieve the loss, these variables may not fully capture the complete grief experience in fathers.

Many theorists believe fathers have unique, indirect ways of grieving perinatal losses (Leon, 1990; Phipps, 1981; Zeanah, 1989; Zeanah, Danis, Hirshberg, & Dietz, 1995). Rather than directly expressing their feelings about the loss, they: (a) keep busy so they do not think about the loss; (b) repress their feelings about the loss (Phipps, 1981); (c) suppress their feelings about the loss (Zeanah, 1989); (d) express grief vicariously through their wives (Leon, 1990); (e) or fail to consciously grieve (Zeanah, Danis, Hirshberg, & Dietz, 1995). Therefore, to fully capture the grief reactions of fathers after perinatal loss, it would be useful to examine their unconscious experiences after the loss, or the feelings they may defend against and express only indirectly. Hence, the present study will examine fathers’ conscious and unconscious experiences after perinatal loss through an interview, a grief scale, and two projective tests.

In essence, much of the literature has failed to take into account the unique ways that fathers have of grieving after a perinatal loss. Often, studies tap into conscious manifestations of depression, anxiety, and grief, missing the underlying feelings that may be expressed in other ways. Thus, more research is needed that taps into fathers’ own unique ways of grieving and examines their unconscious experiences. In order to fully capture the grief experiences of fathers, this dissertation will use a psychodynamic lens, seeking to explore fathers’ conscious and unconscious experiences of perinatal loss.

Statement of Purpose

The rationale for studying the fathers’ experiences following perinatal loss is based on several factors. To begin, little is known about how men experience this type of loss. As mentioned above, much of the literature assumes that fathers reactions to this loss are qualitatively similar to mothers’ reactions (Beutal, 1996; Theut, 1990; Vance, et al., 1991). In addition, these methodological limitations may have some implications for clinical theory and practice. The four main clinical implications are as follows. First, mental health professionals may inadvertently underestimate men s distress because they do not exhibit the same symptoms as mothers. Additionally, these men may also underestimate their own levels of distress or attribute this distress to other factors in their life (e.g. stressful work environment). Consequently, fathers may not adequately mourn their losses. Second, the recognition that fathers do experience significant distress, despite their differing symptomatology from mothers, can help to normalize and validate their experience. Thus, they will have the opportunity to effectively mourn their loss, and safely cathart their feelings and vulnerabilities. Third, the awareness of perinatal loss as a significant loss for fathers can guide mental health professionals in re-conceptualizing the construct of fathers grief following perinatal loss, facilitating the development of appropriate treatment approaches. For instance, mental health professionals could take note that unrelated symptoms, such as increased alcohol use, may occur in men as a disguised expression of feelings about the loss. Lastly, an understanding of fathers' reactions following perinatal loss can help couples understand the process of how each individual grieves. This understanding could decrease the possibility of interpersonal strife and conflict between the mother and father, protecting against the threat of separation and divorce.

The rationale for looking at the individual’s conscious and unconscious experience is that little is known about what really happens with men intrapsychically following perinatal loss. To date, no studies have looked at both the conscious and unconscious experience of fathers after a perinatal loss. However, there is some evidence that fathers experience a lot of distress after perinatal loss. For example, to address whether men experience distress after perinatal loss, Vance et al. (1995), looked at gender differences in distress following perinatal loss and Sudden Infant Death Syndrome. Not only did Vance et al. (1995) measure grief, anxiety, and depression, but they also measured alcohol ingestion. Results indicated that when factoring in alcohol ingestion, men did experience just as much distress as women did at fifteen and thirty months following the loss. Thus, we may hypothesize that fathers do experience distress following perinatal loss, but their distress manifests itself in different ways than that of mothers. Because the current literature on perinatal loss lacks an accurate construct for understanding fathers’ experiences after perinatal loss, this dissertation has used a qualitative, rather than a quantitative method of research.

In the present study, an attempt has been made to examine fathers’ conscious experiences via an interview and the Perinatal Grief Scale (PGS), and to examine the unconscious, defended, or indirectly expressed aspects of their experiences via the use of two projective tests: the Thematic Apperception Test (T.A.T.) and the human form of the Children’s Apperception Test (C.A.T.-H). This dissertation provides a more detailed explanation of these tests in Chapter three.

This researcher believes that the meaning of an event to an individual is a crucial factor in determining its impact. Therefore, the present study has adopted a psychodynamic framework for approaching fathers and perinatal loss. To illustrate the full scope of fathers’ experiences of perinatal loss, this dissertation will critically review several important topic areas. First, perinatal loss occurs at the time that fathers are transitioning to fatherhood, so a section on expectant fatherhood will be included. Second, this dissertation will review literature on models and theories of grief to illustrate the “typical” phases of grief. Third, a section describing unique aspects of perinatal loss will be included. Due to the limited literature on the topic of fathers and perinatal loss, this section will review the literature on mothers’ experiences of perinatal loss and attempt to apply this information to fathers. Finally, this literature review will discuss and critique the existing literature on fathers and perinatal loss.

Following the literature review, a chapter describing the specific methodology of this dissertation will be included, as well as the results and the discussion of this study. This investigator has used a parallel model, meaning that the clinical work sample is a separate component to this dissertation and is not in this copy of the document.